Summary of Benefits and Coverage (SBC) FHIR Implementation Guide
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Summary of Benefits and Coverage (SBC) FHIR Implementation Guide, published by SBC FHIR Project. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/jdjkelly/fhir-sbc/ and changes regularly. See the Directory of published versions

Resource Profile: SBC Insurance Plan Profile

Official URL: http://flexpa.com/fhir/sbc/StructureDefinition/sbc-insurance-plan Version: 0.1.0
Draft as of 2025-11-10 Computable Name: SBCInsurancePlan

Profile of InsurancePlan resource for representing Summary of Benefits and Coverage (SBC) documents as required under ACA Section 2715 and implementing regulations at 45 CFR 147.200, 29 CFR 2590.715-2715, and 26 CFR 54.9815-2715

To represent Summary of Benefits and Coverage documents in structured FHIR format, enabling machine-readable representation of the 27 required benefit categories, cost-sharing information, network distinctions, and regulatory disclosures

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. InsurancePlan C 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
Constraints: ipn-1
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:sbcMetadata S 0..1 (Complex) SBC regulatory metadata
URL: http://flexpa.com/fhir/sbc/StructureDefinition/sbc-metadata
.... extension:excludedServices S 0..1 (Complex) Excluded services list
URL: http://flexpa.com/fhir/sbc/StructureDefinition/excluded-services
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code draft | active | retired | unknown
Binding: PublicationStatus (required): The lifecycle status of an artifact.
Fixed Value: active
... name SΣC 1..1 string Plan name as displayed on SBC
... period S 1..1 Period Coverage period
... ownedBy SΣ 1..1 Reference(Organization) Plan issuer organization
... administeredBy SΣ 0..1 Reference(Organization) Plan administrator
... contact S 1..* BackboneElement Contact information for plan questions
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
... coverage S 1..* BackboneElement Benefit coverage details
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 1..1 CodeableConcept Type of coverage (e.g., medical, pharmacy)
Binding: SBC Benefit Category Value Set (extensible)
.... network S 0..* Reference(Organization) Provider networks for this coverage
.... benefit S 1..* BackboneElement Specific benefits covered
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:limitation S 0..* string Limitations and exceptions
URL: http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type S 1..1 CodeableConcept Benefit category code
Binding: SBC Benefit Category Value Set (required)
..... requirement S 0..1 string Requirements for accessing benefit
... plan S 1..* BackboneElement Health insurance plan details
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 0..1 CodeableConcept Plan type (HMO, PPO, POS, EPO, etc.)
Binding: SBC Plan Type Value Set (extensible)
.... coverageArea SΣ 0..* Reference(Location) Geographic coverage area
.... network S 0..* Reference(Organization) Provider networks for this plan
.... generalCost S 0..* BackboneElement Overall plan costs
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type S 0..1 CodeableConcept Type of cost (deductible, out-of-pocket max)
..... cost S 0..1 Money Cost amount
..... comment S 0..1 string Additional cost information
.... specificCost S 1..* BackboneElement Cost-sharing by benefit category
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Benefit category code
Binding: SBC Benefit Category Value Set (required)
..... benefit S 1..* BackboneElement Specific benefit with costs
...... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
....... extension:limitation S 0..* string Benefit-specific limitations
URL: http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... type S 1..1 CodeableConcept Benefit type code
Binding: SBC Benefit Category Value Set (required)
...... cost S 2..* BackboneElement Cost-sharing amounts
....... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
....... type S 1..1 CodeableConcept Type of cost (copay, coinsurance, deductible)
....... applicability S 1..1 CodeableConcept Network applicability (in-network, out-of-network)
Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
....... value S 1..1 Quantity Cost amount

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
InsurancePlan.status Base required PublicationStatus 📍4.0.1 FHIR Std.
InsurancePlan.coverage.​type Base extensible SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.coverage.​benefit.type Base required SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.plan.type Base extensible SBC Plan Type Value Set 📦0.1.0 This IG
InsurancePlan.plan.specificCost.​category Base required SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.plan.specificCost.​benefit.type Base required SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.plan.specificCost.​benefit.cost.applicability Base required Benefit cost applicability 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error InsurancePlan If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error InsurancePlan If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice InsurancePlan A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
ipn-1 error InsurancePlan The organization SHALL at least have a name or an idendtifier, and possibly more than one (identifier.count() + name.count()) > 0

This structure is derived from InsurancePlan

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. InsurancePlan 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:sbcMetadata S 0..1 (Complex) SBC regulatory metadata
URL: http://flexpa.com/fhir/sbc/StructureDefinition/sbc-metadata
.... extension:excludedServices S 0..1 (Complex) Excluded services list
URL: http://flexpa.com/fhir/sbc/StructureDefinition/excluded-services
... identifier S 0..* Identifier Business identifier for the insurance plan (e.g., HIOS ID)
... status S 1..1 code draft | active | retired | unknown
Fixed Value: active
... period S 1..1 Period Coverage period
... ownedBy S 1..1 Reference(Organization) Plan issuer organization
... administeredBy S 0..1 Reference(Organization) Plan administrator
... contact S 1..* BackboneElement Contact information for plan questions
... coverage S 1..* BackboneElement Benefit coverage details
.... type S 1..1 CodeableConcept Type of coverage (e.g., medical, pharmacy)
Binding: SBC Benefit Category Value Set (extensible)
.... network S 0..* Reference(Organization) Provider networks for this coverage
.... benefit S 1..* BackboneElement Specific benefits covered
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:limitation S 0..* string Limitations and exceptions
URL: http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation
..... type S 1..1 CodeableConcept Benefit category code
Binding: SBC Benefit Category Value Set (required)
..... requirement S 0..1 string Requirements for accessing benefit
... plan S 1..* BackboneElement Health insurance plan details
.... type S 0..1 CodeableConcept Plan type (HMO, PPO, POS, EPO, etc.)
Binding: SBC Plan Type Value Set (extensible)
.... coverageArea S 0..* Reference(Location) Geographic coverage area
.... network S 0..* Reference(Organization) Provider networks for this plan
.... generalCost S 0..* BackboneElement Overall plan costs
..... type S 0..1 CodeableConcept Type of cost (deductible, out-of-pocket max)
..... cost S 0..1 Money Cost amount
..... comment S 0..1 string Additional cost information
.... specificCost S 1..* BackboneElement Cost-sharing by benefit category
..... category S 1..1 CodeableConcept Benefit category code
Binding: SBC Benefit Category Value Set (required)
..... benefit S 1..* BackboneElement Specific benefit with costs
...... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
....... extension:limitation S 0..* string Benefit-specific limitations
URL: http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation
...... type S 1..1 CodeableConcept Benefit type code
Binding: SBC Benefit Category Value Set (required)
...... cost S 2..* BackboneElement Cost-sharing amounts
....... type S 1..1 CodeableConcept Type of cost (copay, coinsurance, deductible)
....... applicability S 1..1 CodeableConcept Network applicability (in-network, out-of-network)
....... value S 1..1 Quantity Cost amount

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
InsurancePlan.coverage.​type Base extensible SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.coverage.​benefit.type Base required SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.plan.type Base extensible SBC Plan Type Value Set 📦0.1.0 This IG
InsurancePlan.plan.specificCost.​category Base required SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.plan.specificCost.​benefit.type Base required SBC Benefit Category Value Set 📦0.1.0 This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. InsurancePlan C 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
Constraints: ipn-1
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:sbcMetadata S 0..1 (Complex) SBC regulatory metadata
URL: http://flexpa.com/fhir/sbc/StructureDefinition/sbc-metadata
.... extension:excludedServices S 0..1 (Complex) Excluded services list
URL: http://flexpa.com/fhir/sbc/StructureDefinition/excluded-services
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣC 0..* Identifier Business identifier for the insurance plan (e.g., HIOS ID)
... status ?!SΣ 1..1 code draft | active | retired | unknown
Binding: PublicationStatus (required): The lifecycle status of an artifact.
Fixed Value: active
... type Σ 0..* CodeableConcept Kind of product
Binding: InsurancePlanType (example): Used to categorize the product/plan.
... name SΣC 1..1 string Plan name as displayed on SBC
... alias 0..* string Alternate names
... period S 1..1 Period Coverage period
... ownedBy SΣ 1..1 Reference(Organization) Plan issuer organization
... administeredBy SΣ 0..1 Reference(Organization) Plan administrator
... coverageArea Σ 0..* Reference(Location) Where product applies
... contact S 1..* BackboneElement Contact information for plan questions
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... purpose 0..1 CodeableConcept The type of contact
Binding: ContactEntityType (extensible): The purpose for which you would contact a contact party.
.... name 0..1 HumanName A name associated with the contact
.... telecom 0..* ContactPoint Contact details (telephone, email, etc.) for a contact
.... address 0..1 Address Visiting or postal addresses for the contact
... endpoint 0..* Reference(Endpoint) Technical endpoint
... network 0..* Reference(Organization) What networks are Included
... coverage S 1..* BackboneElement Benefit coverage details
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 1..1 CodeableConcept Type of coverage (e.g., medical, pharmacy)
Binding: SBC Benefit Category Value Set (extensible)
.... network S 0..* Reference(Organization) Provider networks for this coverage
.... benefit S 1..* BackboneElement Specific benefits covered
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:limitation S 0..* string Limitations and exceptions
URL: http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type S 1..1 CodeableConcept Benefit category code
Binding: SBC Benefit Category Value Set (required)
..... requirement S 0..1 string Requirements for accessing benefit
..... limit 0..* BackboneElement Benefit limits
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... value 0..1 Quantity Maximum value allowed
...... code 0..1 CodeableConcept Benefit limit details
... plan S 1..* BackboneElement Health insurance plan details
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... identifier Σ 0..* Identifier Business Identifier for Product
.... type S 0..1 CodeableConcept Plan type (HMO, PPO, POS, EPO, etc.)
Binding: SBC Plan Type Value Set (extensible)
.... coverageArea SΣ 0..* Reference(Location) Geographic coverage area
.... network S 0..* Reference(Organization) Provider networks for this plan
.... generalCost S 0..* BackboneElement Overall plan costs
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type S 0..1 CodeableConcept Type of cost (deductible, out-of-pocket max)
..... groupSize 0..1 positiveInt Number of enrollees
..... cost S 0..1 Money Cost amount
..... comment S 0..1 string Additional cost information
.... specificCost S 1..* BackboneElement Cost-sharing by benefit category
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Benefit category code
Binding: SBC Benefit Category Value Set (required)
..... benefit S 1..* BackboneElement Specific benefit with costs
...... id 0..1 string Unique id for inter-element referencing
...... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
....... extension:limitation S 0..* string Benefit-specific limitations
URL: http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... type S 1..1 CodeableConcept Benefit type code
Binding: SBC Benefit Category Value Set (required)
...... cost S 2..* BackboneElement Cost-sharing amounts
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
....... type S 1..1 CodeableConcept Type of cost (copay, coinsurance, deductible)
....... applicability S 1..1 CodeableConcept Network applicability (in-network, out-of-network)
Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
....... qualifiers 0..* CodeableConcept Additional information about the cost
....... value S 1..1 Quantity Cost amount

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
InsurancePlan.language Base preferred Common Languages 📍4.0.1 FHIR Std.
InsurancePlan.status Base required PublicationStatus 📍4.0.1 FHIR Std.
InsurancePlan.type Base example Insurance plan type 📍4.0.1 FHIR Std.
InsurancePlan.contact.​purpose Base extensible Contact entity type 📍4.0.1 FHIR Std.
InsurancePlan.coverage.​type Base extensible SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.coverage.​benefit.type Base required SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.plan.type Base extensible SBC Plan Type Value Set 📦0.1.0 This IG
InsurancePlan.plan.specificCost.​category Base required SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.plan.specificCost.​benefit.type Base required SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.plan.specificCost.​benefit.cost.applicability Base required Benefit cost applicability 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error InsurancePlan If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error InsurancePlan If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice InsurancePlan A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
ipn-1 error InsurancePlan The organization SHALL at least have a name or an idendtifier, and possibly more than one (identifier.count() + name.count()) > 0

This structure is derived from InsurancePlan

Summary

Mandatory: 11 elements
Must-Support: 33 elements
Fixed: 1 element

Extensions

This structure refers to these extensions:

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. InsurancePlan C 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
Constraints: ipn-1
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:sbcMetadata S 0..1 (Complex) SBC regulatory metadata
URL: http://flexpa.com/fhir/sbc/StructureDefinition/sbc-metadata
.... extension:excludedServices S 0..1 (Complex) Excluded services list
URL: http://flexpa.com/fhir/sbc/StructureDefinition/excluded-services
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code draft | active | retired | unknown
Binding: PublicationStatus (required): The lifecycle status of an artifact.
Fixed Value: active
... name SΣC 1..1 string Plan name as displayed on SBC
... period S 1..1 Period Coverage period
... ownedBy SΣ 1..1 Reference(Organization) Plan issuer organization
... administeredBy SΣ 0..1 Reference(Organization) Plan administrator
... contact S 1..* BackboneElement Contact information for plan questions
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
... coverage S 1..* BackboneElement Benefit coverage details
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 1..1 CodeableConcept Type of coverage (e.g., medical, pharmacy)
Binding: SBC Benefit Category Value Set (extensible)
.... network S 0..* Reference(Organization) Provider networks for this coverage
.... benefit S 1..* BackboneElement Specific benefits covered
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:limitation S 0..* string Limitations and exceptions
URL: http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type S 1..1 CodeableConcept Benefit category code
Binding: SBC Benefit Category Value Set (required)
..... requirement S 0..1 string Requirements for accessing benefit
... plan S 1..* BackboneElement Health insurance plan details
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 0..1 CodeableConcept Plan type (HMO, PPO, POS, EPO, etc.)
Binding: SBC Plan Type Value Set (extensible)
.... coverageArea SΣ 0..* Reference(Location) Geographic coverage area
.... network S 0..* Reference(Organization) Provider networks for this plan
.... generalCost S 0..* BackboneElement Overall plan costs
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type S 0..1 CodeableConcept Type of cost (deductible, out-of-pocket max)
..... cost S 0..1 Money Cost amount
..... comment S 0..1 string Additional cost information
.... specificCost S 1..* BackboneElement Cost-sharing by benefit category
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Benefit category code
Binding: SBC Benefit Category Value Set (required)
..... benefit S 1..* BackboneElement Specific benefit with costs
...... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
....... extension:limitation S 0..* string Benefit-specific limitations
URL: http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... type S 1..1 CodeableConcept Benefit type code
Binding: SBC Benefit Category Value Set (required)
...... cost S 2..* BackboneElement Cost-sharing amounts
....... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
....... type S 1..1 CodeableConcept Type of cost (copay, coinsurance, deductible)
....... applicability S 1..1 CodeableConcept Network applicability (in-network, out-of-network)
Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
....... value S 1..1 Quantity Cost amount

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
InsurancePlan.status Base required PublicationStatus 📍4.0.1 FHIR Std.
InsurancePlan.coverage.​type Base extensible SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.coverage.​benefit.type Base required SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.plan.type Base extensible SBC Plan Type Value Set 📦0.1.0 This IG
InsurancePlan.plan.specificCost.​category Base required SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.plan.specificCost.​benefit.type Base required SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.plan.specificCost.​benefit.cost.applicability Base required Benefit cost applicability 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error InsurancePlan If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error InsurancePlan If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice InsurancePlan A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
ipn-1 error InsurancePlan The organization SHALL at least have a name or an idendtifier, and possibly more than one (identifier.count() + name.count()) > 0

Differential View

This structure is derived from InsurancePlan

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. InsurancePlan 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:sbcMetadata S 0..1 (Complex) SBC regulatory metadata
URL: http://flexpa.com/fhir/sbc/StructureDefinition/sbc-metadata
.... extension:excludedServices S 0..1 (Complex) Excluded services list
URL: http://flexpa.com/fhir/sbc/StructureDefinition/excluded-services
... identifier S 0..* Identifier Business identifier for the insurance plan (e.g., HIOS ID)
... status S 1..1 code draft | active | retired | unknown
Fixed Value: active
... period S 1..1 Period Coverage period
... ownedBy S 1..1 Reference(Organization) Plan issuer organization
... administeredBy S 0..1 Reference(Organization) Plan administrator
... contact S 1..* BackboneElement Contact information for plan questions
... coverage S 1..* BackboneElement Benefit coverage details
.... type S 1..1 CodeableConcept Type of coverage (e.g., medical, pharmacy)
Binding: SBC Benefit Category Value Set (extensible)
.... network S 0..* Reference(Organization) Provider networks for this coverage
.... benefit S 1..* BackboneElement Specific benefits covered
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:limitation S 0..* string Limitations and exceptions
URL: http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation
..... type S 1..1 CodeableConcept Benefit category code
Binding: SBC Benefit Category Value Set (required)
..... requirement S 0..1 string Requirements for accessing benefit
... plan S 1..* BackboneElement Health insurance plan details
.... type S 0..1 CodeableConcept Plan type (HMO, PPO, POS, EPO, etc.)
Binding: SBC Plan Type Value Set (extensible)
.... coverageArea S 0..* Reference(Location) Geographic coverage area
.... network S 0..* Reference(Organization) Provider networks for this plan
.... generalCost S 0..* BackboneElement Overall plan costs
..... type S 0..1 CodeableConcept Type of cost (deductible, out-of-pocket max)
..... cost S 0..1 Money Cost amount
..... comment S 0..1 string Additional cost information
.... specificCost S 1..* BackboneElement Cost-sharing by benefit category
..... category S 1..1 CodeableConcept Benefit category code
Binding: SBC Benefit Category Value Set (required)
..... benefit S 1..* BackboneElement Specific benefit with costs
...... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
....... extension:limitation S 0..* string Benefit-specific limitations
URL: http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation
...... type S 1..1 CodeableConcept Benefit type code
Binding: SBC Benefit Category Value Set (required)
...... cost S 2..* BackboneElement Cost-sharing amounts
....... type S 1..1 CodeableConcept Type of cost (copay, coinsurance, deductible)
....... applicability S 1..1 CodeableConcept Network applicability (in-network, out-of-network)
....... value S 1..1 Quantity Cost amount

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
InsurancePlan.coverage.​type Base extensible SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.coverage.​benefit.type Base required SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.plan.type Base extensible SBC Plan Type Value Set 📦0.1.0 This IG
InsurancePlan.plan.specificCost.​category Base required SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.plan.specificCost.​benefit.type Base required SBC Benefit Category Value Set 📦0.1.0 This IG

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. InsurancePlan C 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
Constraints: ipn-1
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:sbcMetadata S 0..1 (Complex) SBC regulatory metadata
URL: http://flexpa.com/fhir/sbc/StructureDefinition/sbc-metadata
.... extension:excludedServices S 0..1 (Complex) Excluded services list
URL: http://flexpa.com/fhir/sbc/StructureDefinition/excluded-services
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣC 0..* Identifier Business identifier for the insurance plan (e.g., HIOS ID)
... status ?!SΣ 1..1 code draft | active | retired | unknown
Binding: PublicationStatus (required): The lifecycle status of an artifact.
Fixed Value: active
... type Σ 0..* CodeableConcept Kind of product
Binding: InsurancePlanType (example): Used to categorize the product/plan.
... name SΣC 1..1 string Plan name as displayed on SBC
... alias 0..* string Alternate names
... period S 1..1 Period Coverage period
... ownedBy SΣ 1..1 Reference(Organization) Plan issuer organization
... administeredBy SΣ 0..1 Reference(Organization) Plan administrator
... coverageArea Σ 0..* Reference(Location) Where product applies
... contact S 1..* BackboneElement Contact information for plan questions
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... purpose 0..1 CodeableConcept The type of contact
Binding: ContactEntityType (extensible): The purpose for which you would contact a contact party.
.... name 0..1 HumanName A name associated with the contact
.... telecom 0..* ContactPoint Contact details (telephone, email, etc.) for a contact
.... address 0..1 Address Visiting or postal addresses for the contact
... endpoint 0..* Reference(Endpoint) Technical endpoint
... network 0..* Reference(Organization) What networks are Included
... coverage S 1..* BackboneElement Benefit coverage details
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 1..1 CodeableConcept Type of coverage (e.g., medical, pharmacy)
Binding: SBC Benefit Category Value Set (extensible)
.... network S 0..* Reference(Organization) Provider networks for this coverage
.... benefit S 1..* BackboneElement Specific benefits covered
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:limitation S 0..* string Limitations and exceptions
URL: http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type S 1..1 CodeableConcept Benefit category code
Binding: SBC Benefit Category Value Set (required)
..... requirement S 0..1 string Requirements for accessing benefit
..... limit 0..* BackboneElement Benefit limits
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... value 0..1 Quantity Maximum value allowed
...... code 0..1 CodeableConcept Benefit limit details
... plan S 1..* BackboneElement Health insurance plan details
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... identifier Σ 0..* Identifier Business Identifier for Product
.... type S 0..1 CodeableConcept Plan type (HMO, PPO, POS, EPO, etc.)
Binding: SBC Plan Type Value Set (extensible)
.... coverageArea SΣ 0..* Reference(Location) Geographic coverage area
.... network S 0..* Reference(Organization) Provider networks for this plan
.... generalCost S 0..* BackboneElement Overall plan costs
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type S 0..1 CodeableConcept Type of cost (deductible, out-of-pocket max)
..... groupSize 0..1 positiveInt Number of enrollees
..... cost S 0..1 Money Cost amount
..... comment S 0..1 string Additional cost information
.... specificCost S 1..* BackboneElement Cost-sharing by benefit category
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Benefit category code
Binding: SBC Benefit Category Value Set (required)
..... benefit S 1..* BackboneElement Specific benefit with costs
...... id 0..1 string Unique id for inter-element referencing
...... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
....... extension:limitation S 0..* string Benefit-specific limitations
URL: http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... type S 1..1 CodeableConcept Benefit type code
Binding: SBC Benefit Category Value Set (required)
...... cost S 2..* BackboneElement Cost-sharing amounts
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
....... type S 1..1 CodeableConcept Type of cost (copay, coinsurance, deductible)
....... applicability S 1..1 CodeableConcept Network applicability (in-network, out-of-network)
Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
....... qualifiers 0..* CodeableConcept Additional information about the cost
....... value S 1..1 Quantity Cost amount

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
InsurancePlan.language Base preferred Common Languages 📍4.0.1 FHIR Std.
InsurancePlan.status Base required PublicationStatus 📍4.0.1 FHIR Std.
InsurancePlan.type Base example Insurance plan type 📍4.0.1 FHIR Std.
InsurancePlan.contact.​purpose Base extensible Contact entity type 📍4.0.1 FHIR Std.
InsurancePlan.coverage.​type Base extensible SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.coverage.​benefit.type Base required SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.plan.type Base extensible SBC Plan Type Value Set 📦0.1.0 This IG
InsurancePlan.plan.specificCost.​category Base required SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.plan.specificCost.​benefit.type Base required SBC Benefit Category Value Set 📦0.1.0 This IG
InsurancePlan.plan.specificCost.​benefit.cost.applicability Base required Benefit cost applicability 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error InsurancePlan If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error InsurancePlan If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice InsurancePlan A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
ipn-1 error InsurancePlan The organization SHALL at least have a name or an idendtifier, and possibly more than one (identifier.count() + name.count()) > 0

This structure is derived from InsurancePlan

Summary

Mandatory: 11 elements
Must-Support: 33 elements
Fixed: 1 element

Extensions

This structure refers to these extensions:

 

Other representations of profile: CSV, Excel, Schematron